Everything You Need to Know About RED-S and the Female Athlete Triad

Written By Mackenzie Hayden

I wrote this article for all of my fellow athletes out there, back in 2022 while I was recovering from my eating disorder. As a former competitive athlete whose career was stunted as result of disordered eating, chronic under-fueling, and overtraining, there is so much that I wish I could have told my younger self. When I first entered the world of competitive running, I firmly believed the notion that “smaller equaled faster.” I wish I could tell that version of myself that the secret to success was not found in restriction and dieting; it would be found in self care.

I was prompted to write this nearly four years ago, following an article I’d read from Runner’s World. Promoting mental and physical health in sport is of utmost importance to me, and I greatly admire the recent pushes for inclusivity of both male and female runners alike. What is now known as Relative Energy Deficiency in Sport Syndrome was once referred to as ‘The Female Athlete Triad.’ It was deemed exclusively a feminine issue, leaving a plethora of sufferers undiagnosed, due to the inability to meet one of the diagnostic criteria; the menstrual cycle. Historically, illnesses pertaining to disordered eating met a similar fate, and it wasn’t until 1994 that amenorrhea was removed as a necessary criterion.

Nowadays, it is more widely acknowledged that both men and women can (and do) struggle with disordered eating and over-exercise. It is of immense importance that we, as a society, recognize these diagnostic abnormalities and behaviors in all athletes in which they present; taking initiative in preventing career-ending illnesses and injuries brought forth by chronic under-fueling and over-training. It is key that mental and physical wellbeing is emphasized over performance; because as athletes, performance will be at it’s best when an athlete is their healthiest AND happiest self!

So… What is RED-S?

RED-S stands for ‘Relative Energy Deficiency in Sport Syndrome.’ It is a newer term, adopted in 2014, used to describe what was formerly referred to as ‘The Female Athlete Triad.’ Upon it’s renaming, the characterization of the phenomenon also changed, making it inclusive to all athletes both female, and male. When an athlete presents with symptoms of RED-S, it implies that energy is insufficient relative to energy output. It impacts a variety of essential functions, some of which include the metabolism, menstruation, bone health, immune health, cardiovascular health, and psychological wellbeing.

Characterizing RED-S

Diagnostic criteria for RED-S are as follows:

  • Low Energy Availability: characterized by the loss of strength. When this occurs, the body begins to break down skeletal muscle to maintain necessary bodily functions (that of the cardiovascular and respiratory systems), as it lacks the energy stores needed otherwise. Repeated injuries, delayed healing, and impaired cognitive function are also reported.

  • Decreased Bone Density: indicated by stress injuries, caused by insufficient eating habits coupled with excessive or intense exercise.

  • Amenorrhea: a hormone imbalance causing energy levels to drop and a cease in menstruation. further implications include bone loss.

RED-S and the Menstrual Cycle

As per an article published by Runner’s World in 2022, “female athletes are more likely to be restrictive with their eating,” and “commonly cut back on calories when they should be adding more instead” (Kuzma, 2022). Carbohydrates are the most commonly avoided macronutrient by female athletes, despite their importance in the restoration and maintenance of the menstrual cycle. This macronutrient is the preferred energy source for both the muscles and the brain, and shortage of intake proves especially dire in the athletic population.

When an energy deficit is detected in athletes with a menstrual cycle, it is often because estrogen levels have dropped, causing menstruation to cease. This leads to aforementioned bone loss, prompting further complications such as stress fractures and unexplained injuries.

RED-S When Menstruation is Not a Diagnostic Criterion

RED-S details complications caused by both intentional and unintentional cases of under-fueling. In individuals with a menstrual cycle, RED-S is easier to detect due to a mix of biological and societal factors. In individuals who do not menstruate, diagnosis proves to be difficult. Some common characteristics observed in this population are as follows:

  • Stress injuries

  • Repeated injuries and slow healing processes

  • Excessive fatigue

  • Irregular sleep patterns and sleep disruption

  • Plateau or deterioration in training and performance

  • Aversion to scenarios and social settings involving food

  • Excessive exercise compulsions

Further indication of RED-S:

  • Bradycardia (slow heart rate)

  • Orthostasis (irregularities in heart rate and blood pressure)

  • Persistent gastrointestinal issues

  • Cold intolerance

  • Dramatic weight loss

  • Excessive need to use the restroom

  • Increased anxiety and depression

  • Dental issues and bad breath

  • Muscle fatigue and weakness

  • Impaired concentration

  • Preoccupation with weight and body image

  • Infatuation with food despite aversion to eating

How Best to Promote Positive Mental and Physical Health in Sport

Move your body in ways you love, when you feel like it! Exercise is a celebration of what your body can do, and should never serve as a punishment. You will find that you perform and feel your best when you are the healthiest (and happiest) version of yourself. Emphasize more nutrients and more energy during a training block, not fewer calories.

Prioritize both your mental and physical health. Your overall wellbeing comes before your athletic status. Being an athlete is wonderful, but you are more than that! Surround yourself with people who support you for the right reasons; those who truly want the best for you!

Practice body neutrality and acceptance. Celebrate your body for all that it does for you, not what it looks like! Maybe even ditch the scale, if it is triggering! Your weight does not determine your worth.

Take it from me, life is so much happier in a healthy, nourished body! Left long-term, RED-S can have serious implications on both male and female athletes alike, some of which are even career-ending. You deserve to make the most out of your athletic career, and the beautiful life that lies ahead of you.

References:

Brown University. Relative Energy Deficiency in Sport (RED-S) | Health Promotion | Brown University. (2022). https://www.brown.edu/campus-life/health/services/promotion/nutrition-eating-concerns-sports-nutrition/relative-energy-deficiency-sport-red-s

"How I went from dieting to intuitive eating." Youtube. 12 May 2021. www.youtube.com/watch?v=m1HnpGEFSjs.

Kuzma, C. (2022). How red-S can affect male athletes - relative energy deficiency in sport. Runner’s World. https://www.runnersworld.com/nutrition-weight-loss/a40303925/red-s-in-male-runners/

Ward, A. (2022). Moving beyond the female athlete triad: Signs of red-S in men. Custom Performance. https://www.nycustompt.com/signs-of-red-s-in-men/

Mackenzie Hayden